The echocardiogram effect on length of stay

From the 2022 HVPA National Conference

Alisha Maity MD (Lankenau Medical Center), Anna Sunnergren DO, Stephanie Kjelstrom MPH, CPH, Georgia Montone BS, Brian Sturgis BI, Erin Carnish MD, William Surkis MD

Background

Length of stay (LOS) is an important quality metric that has consequential outcomes. Concern was noted that heart failure patients’ LOS may be prolonged by the need for echocardiograms prior to discharge. We have explored the impact of echocardiogram order day upon LOS.

Objective

To assess if echocardiogram orders placed Friday through Sunday were associated with longer LOS and order to discharge times than orders placed on Monday through Thursday. 

Methods

All inpatients with a diagnosis of congestive heart failure (CHF) and imaging done while admitted were included in the analysis. The day that echocardiograms were ordered was categorized into two groups, Monday to Thursday and Friday to Sunday. A variable was created to measure the time from imaging order to discharge. Wilcoxon rank-sum or two-sample t-test and chi-square test for independence were used to compare continuous and categorical data, respectively. Unadjusted and adjusted linear regression models were built to assess the relationship between LOS and day that echocardiogram was ordered, and time from order to discharge and day echocardiogram was ordered. 95% confidence levels and p values are reported, with an alpha level of 0.05. All analyses were done in Stata 17.0 (Stata, LLC. College Station, TX).

Results

There was a total of 22,456 CHF inpatients from March 2018 to March 2022 who had echocardiograms during their stay. Of those, 15,748 (70%) had echocardiograms ordered on Monday – Thursday and 6,708 (30%) had echocardiograms ordered on Friday – Sunday. There was a statistical difference in overall LOS between the two ordering groups, with patients with orders placed on Monday – Thursday having a median LOS of 5.4 days (IQR 3-9.8) and those with orders placed on Friday – Sunday having a median LOS of 6 days (IQR 4-10.1) (p = 0.0009). Time from imaging to discharge also differed significantly between ordering groups. Those with orders on Monday – Thursday had a median 4.6 days (IQR 2.6-7.8) between order and discharge and those with orders on Friday – Sunday had a median 5.6 days (IQR 3.7-8.7) (p<.0001). Having an echocardiogram ordered on Friday – Sunday compared to Monday – Thursday was significantly related to a higher mean LOS of 0.43 days (95% CI 0.18, 0.7).

Conclusions

Based on our results, LOS is longer when echocardiogram orders are placed Friday – Sunday versus Monday – Thursday. We postulate that this likely relates to differences in staffing on weekends, making echocardiograms less accessible.

Clinical Implications

Prolonged LOS disrupts patient flow, increases bed shortages, increases hospital-acquired infections, and has significant financial implications. This is especially important in a post-COVID world where extraordinary patient volume has overwhelmed hospital systems and normalized extended periods of divert. In order to optimize care transitions such as discharge, we plan to collaborate with our cardiology colleagues to develop interventions that can change hospital workflow, while still respecting the importance of work-life balance for staff.

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